Propranolol

Propranolol is indicated for the treatment of hypertension (high blood pressure). angina pectoris, atrial fibrillation, myocardial infarction, migraine, essential tremor, hypertrophic subaortic stenosis, and pheochromocytoma (catecholamine-secreting tumors).

Propranolol is also indicated for the treatment of proliferating infantile hemangioma requiring systemic therapy.

Beta blockers were once a first-line treatment for hypertension in the United Kingdom. They were downgraded to fourth-line in 2006 because they do not perform as well as other drugs, particularly in the elderly, and there is increasing evidence that the most common beta blockers at usual doses carry an unacceptable risk of provoking type 2 diabetes.

Propranolol is not recommended for the treatment of high blood pressure by the Eighth Joint National Committee (JNC 8) because a higher rate of the primary composite outcome of cardiovascular death, myocardial infarction, or stroke compared to an angiotensin receptor blocker was noted in one study.

Propranolol is occasionally used to treat performance anxiety, although evidence to support its use in any anxiety disorders is poor. Its efficacy in managing panic disorder appears similar to benzodiazepines, while carrying lower risks for addiction or abuse. Although beta blockers such as propranolol have been suggested to be beneficial in managing physical symptoms of anxiety, its efficacy in treating generalized anxiety disorder and panic disorder remain unestablished. It is thought that beta blockers do not directly treat psychological symptoms of anxiety, but can help control physical symptoms such as palpitations and tremors. This may interfere with a positive feedback loop to indirectly reduce psychological anxiety.

A 2025 systematic review and meta-analysis found widespread prescription of beta blockers, namely propranolol, for treatment of anxiety disorders, but found no evidence of a beneficial effect relative to placebo or benzodiazepines in people with social phobia or panic disorder. However, the quality of evidence, including both numbers of studies and patients as well as quality and risk of bias of those studies, was limited. …

Contraindications of propranolol include cardiogenic shock, sinus bradycardia (slow heart rate; <60 beats/minute), heart block greater than first degree, bronchial asthma, overt heart failure, and known hypersensitivity to propranolol. Other contraindications include reversible airway diseases, particularly asthma or chronic obstructive pulmonary disease (COPD), sick sinus syndrome, atrioventricular block (second- or third-degree), circulatory shock, and severe hypotension (low blood pressure).

Propranolol is classified as pregnancy category as Australian Drug Evaluation Committee (ADEC) category C. Beta-blocking agents in general reduce perfusion of the placenta, which may lead to adverse outcomes for the neonate, including lung or heart complications, or premature birth. The newborn may experience additional adverse effects such as low blood sugar and a slower than normal heart rate.

Propranolol is highly bound to proteins in the bloodstream and is distributed into breast milk at very low levels. These low levels are not expected to pose any risk to the breastfeeding infant, and the American Academy of Pediatrics considers propranolol therapy "generally compatible with breastfeeding."

Propranolol overdose has been associated with symptoms including bradycardia and hypotension. These symptoms may be managed by drugs including glucagon, isoprenaline (isoproterenol), dopamine, phosphodiesterase inhibitors, or atropine, whereas epinephrine may provoke uncontrolled hypertension due to unopposed alpha stimulation and is not indicated. Propranolol overdose has also been associated with seizures. Cardiac arrest may occur in propranolol overdose due to sudden ventricular arrhythmias, or cardiogenic shock which may ultimately culminate in bradycardic PEA.

Since beta blockers are known to relax the cardiac muscle and constrict the smooth muscle, they have an additive effect with other drugs that decrease blood pressure or decrease cardiac contractility or conductivity. Pharmacodynamic interactions may occur with other drugs affecting the cardiovascular system, including propafenone, quinidine, amiodarone, cardiac glycosides, calcium channel blockers like verapamil and diltiazem, ACE inhibitors, alpha blockers like prazosin, catecholamine-depleting drugs like reserpine, ergot alkaloids, and adrenergic receptor agonists including epinephrine (adrenaline), isoprenaline (isoproterenol), dobutamine, β2-adrenergic receptor agonists like salbutamol, levosalbutamol, formoterol, salmeterol, and clenbuterol, and α2-adrenergic receptor agonists like clonidine. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have hypotensive side effects and these may be exacerbated by propranolol. Hypotension and cardiac arrest have been reported with the combination of propranolol and haloperidol. Nonsteroidal anti-inflammatory drugs (NSAIDs), which include drugs like ibuprofen, naproxen, and aspirin, have been reported to blunt the antihypertensive effects of beta blockers like propranolol. The NSAID indomethacin specifically may reduce the efficacy of propranolol in decreasing heart rate and blood pressure.

Propranolol is metabolized by cytochrome P450 enzymes including CYP2D6, CYP1A2, and CYP2C19. Levels of propranolol may be increased by CYP2D6 inhibitors such as amiodarone, bupropion, cimetidine, duloxetine, fluoxetine, paroxetine, propafenone, quinidine, and ritonavir, by CYP1A2 inhibitors such as imipramine, cimetidine, ciprofloxacin, fluvoxamine, isoniazid, theophylline, zileuton, zolmitriptan, and rizatriptan, and by CYP2C19 inhibitors such as fluconazole, cimetidine, fluoxetine, fluvoxamine, teniposide, and tolbutamide. No interactions with propranolol were observed with ranitidine, lansoprazole, or omeprazole. Propranolol levels may be reduced by inducers of hepatic metabolism including rifampin, alcohol, phenytoin, phenobarbital, and cigarette smoking.

The CYP2D6 inhibitor quinidine has been found to increase propranolol levels by 2- to 3-fold. The CYP1A2 inhibitor fluvoxamine has been found to increase propranolol levels by 5-fold. …